Q: How should I query for systemic inflammatory response syndrome (SIRS) if SIRS codes to sepsis? I want to correctly query and obtain the proper supporting information in the medical record in the event of an audit. Any discussion on this topic is appreciated.Read More »
Q: Our small hospital has decided at this time that they no longer need the services of a Physician Advisor (PA). He will only be here another sixty days. Can you tell me from your perspective why a hospital should have a PA?Read More »
Q: Are there any coding guidelines/definitions regarding code 518.5 (Pulmonary insufficiency following trauma and surgery) vs. the use of 518.81 (Acute respiratory failure postop)? If a physician documents postop respiratory failure, which code should we report? I looked in Coding Clinic...Read More »
Q: Our physician provided an illegible diagnosis of malnutrition, and when we queried him regarding the specific type of malnutrition, he provided protein malnutrition. The ICD-9-CMCoding Manual directs us to assign code 260;...Read More »
ACDIS Associate Editorial Director Linnea Archibald sends out “missed connections” emails with questions from Council members on a regular basis. Anyone with experience related to one of the questions was invited to respond and Archibald connected them with the question-asker. In order to share...Read More »
This is a classic documentation opportunity to clarify “volume/fluid overload,” says Lynne Spryszak, RN, CPC-A, CCDS, CDI education director for HCPro, Inc., in Danvers, MA. “If the physician hasn’t documented acute CHF, I would hesitate to ask for this condition based on this mild BNP elevation...Read More »
